CONNECTICUT COMMUNITY COLLEGE NURSING PROGRAM (CT-CCNP) Capital Community College, Gateway Community College, Norwalk Community College, Naugatuck Valley Community College, Three Rivers Community College Clinical Learning Experience Workbook Process Recording CLEW Process Recording For Nursing 201 Clinical Learning Experiences August 2009
The Process Recording The process recording is a written account of an interaction between a client and nurse. Through the reconstruction of the interaction the student is provided with an opportunity to retrospectively examine and analyze his/her communication skills, therapeutic use of self and the client's part in the interaction. The process recording is used to evaluate both client and student behaviors and approaches The nurse analyzes what is said (the content of the interaction) and the flow of the interaction (the process). This analysis augments the nurse's ability to increase awareness of feelings, values, expectation and assumptions. He or she is able to analyze verbal and non-verbal responses. Process recordings help caregivers to distinguish between thoughts and feelings. Client behavior can be retrospectively examined and analyzed with the process recording. Congruency of verbal and non-verbal behaviors are identified. Discuss the terms of completion of your process recording with your clinical instructor. A scoring rubric is attached to guide your completion and to define the scoring of this exercise by your instructor. Submit your process recording on the attached process recording sheets. Process Recording Guidelines for Completion
CT-CCNP 1. Enter the data at the top part of the sheet. The recording is to be made on a meeting with your client. Before the meeting with the client, develop a short-term goal that is client centered and that will serve as a guideline and purpose for the communication/session. The length of time of any given session can vary from 10 minutes to one hour. Refer to your Psychiatric Nursing or Fundamentals of Nursing Textbooks as available in preparation for your process recording with your client (i.e. review of Therapeutic Communication Techniques). 2. Column One/Setting: Describe the setting and your plans to therapeutically approach the client at the beginning of the session with sufficient clarity and detail so that the instructor will be helped in his/her understanding of the situation. The setting includes a description of the physical environment, time, position of you and the client and any other pertinent details. The therapeutic approach includes the verbal and nonverbal therapeutic communication techniques you plan to utilize during the interaction 3. Columns Two & Three/Verbal and Non-Verbal Communication Student and Client: The nonverbal communication of both you and the client is as important as the verbal communication. Identify the nonverbal communication. Is there congruence between the verbal and nonverbal communication? Recording of verbal communication should be verbatim. If the meeting includes a period of an activity that you participate in with the client, record only the beginning, the termination, and what you consider significant material in the remaining time. 4. Column Four/Student s thoughts and feelings concerning the interaction: Describe your reactions to the communication. What kind of emotions did you feel and why? Were you at ease or uncomfortable? Did you feel you had to struggle to remain objective? Did you feel like you could help the client? Did you feel confident at the end of the communication? 5. Column Five/Evaluation/Analysis of the Interaction/include therapeutic techniques/approach applied: a. Your perception of the client's feelings and behaviors b. Defense mechanisms used by the client c. Client's level of insight into problems d. Client s Anxiety level e. Outcomes of therapeutic techniques used f. Alternatives to therapeutic techniques g. Assess the client's needs and your ability to meet one or more of them h. Analyze the effectiveness of the communication to the best of your ability
Process Recording CLIENT INITIALS: AGE: 72 GENDER: F DATE: MEDICAL/SURGICAL DIAGNOSIS: COPD exacerbation STUDENT NAME: PERTINENT NURSING DIAGNOSIS/DIAGNOSES Activity intolerance related to COPD as evidenced by SOB on exertion and patient oxygen saturation declining during ambulation. SHORT TERM GOAL(S) Patient will verbalize strategies for maintaining oxygen saturation >88% while participating in physical activity by the end of her hospital stay. SETTING VERBAL & NONVERBAL COMMUNICATION: STUDENT VERBAL & NONVERBAL COMMUNICATION: CLIENT STUDENT S THOUGHTS AND FEEINGS CONCERNING THE INTERACTION EVALUATION/ANALYSIS OF THE INTERACTION INCLUDE THERAPEUTIC APPROACH/TECHNIQUES APPLIED Patient s room just after returning from walking in hallway. Patient has O2 by NC and has used O2 sat. monitor. Patient sits in chair and I am facing her. My plan is to discuss strategies for maintining O2 sat during activity. I make eye contact with patient and make sure my arms are not crossed. How did you feel while walking in the hallway? Your numbers were better today than yesterday, so that is some improvement. What do you think about that? You have stopped smoking now, so that is a start. Patient looks at me and answers: Pretty good, but I kept worrying about my numbers dropping. Yeah, but they are talking about me wearing this (pointing to O2 tubing) at home, too. I don t want to have to drag this around with me wherever I go. I should have listened to my doctor when he told me to stop smoking all those times. But I just didn t listen. Now look where that got me. I guess. I want her to feel that I am willing to listen to what she has to say to me. She was really focused on the O2 sat monitor while we walked. She really doesn t want to have to be dependent on oxygen at home. She seems pretty upset with herself and realizes that her choice to smoke got her in this situation. I am trying to be positive about the progress and changes that she has made, so she will not be so discouraged. I think that she will give up on positive things if she feels they will not make a difference. Trying to use open ended questions. Showing interest in what she has to say and letting her lead the conversation so I can get more information about how she is thinking about the topic of oxygen at home. I hear you are going to go to pulmonary rehab after you leave the hospital. What do you know about it? She is starting to fiddle with things on her table and rearrange them. It s outpatient for two hours at a time. It s about 30 minutes from my house, so my husband will be able to get me there. She seems to be losing interest in this topic. She seems interested in going. That s good. If she s interested then she will get more out of it. My goal was to try to teach her about pacing herself with activity and breathing effectively while walking. The topic turned to her dislike of the oxygen tubing
That should help you learn how to keep your numbers up. You can work at breathing better and maybe you will not need the oxygen at home afterwards. That would be good. I don t like all the tubes on the floor to trip on. She s looking around at the coil of tubing on the floor and then picking it up to gather it into one clump. and wanting to remain independent of oxygen once she leaves the hospital. Once I saw the way she was thinking, I thought it best to encourage her in her efforts to stop smoking and also to see the value of pulmonary rehab. Okay. I will let you rest now and I will check in on you in a little while. I want to try walking again later without the oxygen on. After I rest a while. Thanks. I can see she is done talking about this topic. Since this patient has a habit of changing topics quickly and having scattered thoughts, I was not surprised to have the conversation go the way it did. Holistic Therapeutic Communication/Process Recording Scoring Rubric NUR*201 Nurses must be able to demonstrate interpersonal and therapeutic communication skills that result in information exchange and effective care within the context of the nursing process. Nursing students in NUR*201 are expected to Utilize therapeutic communication techniques in providing care to individuals, families, and groups with increasingly complex health care problems. (Clinical Objective 4) The following criteria will be applied by your instructor to evaluate your process recording. Utilize these criteria to assist you to meet the expectations of the course to the best of your ability. An overall number is assigned to your process recording on the basis of these criteria as indicated below; four is the highest level of evaluation and one is the lowest. 4. Process recording reflects consistent and skillful use of varied therapeutic communication techniques. The student accurately describes the setting and the goal of the interaction. Student demonstrates therapeutic use of self and is aware of the appropriateness of his /her own responses. The student is able to identify thoughts and feelings concerning the interaction. The student is able to identify blocks to the therapeutic communication process. The student is able to identify the patient s verbal and non verbal communication. The student is able to analyze the content and pattern of communication. The student demonstrates cooperation, respect and courtesy. Reflection and documentation regarding the effectiveness of the communication are evident. 3. Process recording reflects use of many therapeutic communication techniques. The student includes a description of the setting and goal for the interaction. The student demonstrates self awareness and identifies thoughts and feelings. The student shows competence with use of communication techniques. The student identifies client communication patterns. Documentation and reflection reflect attainment of the goal.
2. Process recording reflects use of some communication techniques. There is evidence of basic use of therapeutic communication techniques. The student misinterprets or fails to address the verbal and nonverbal cues of the patient. The student occasionally responds in a nontherapeutic manner (ie. giving advice or false reassurance). Communication lacks clarity, flow and goal orientation. Student exhibits limited awareness regarding therapeutic use of self or thoughts and feelings regarding the interaction. Reflection and documentation are superficial. 1. Process recording reflects minimal use of therapeutic communication techniques. Communication lacks focus, clarity and does not address the bio/psycho/social needs of the client. Blocks to communication are not addressed. The conversation is student nurse centered rather than client centered. The student does not exhibit insight or self awareness regarding the interaction. Reflection and documentation is minimal.